Navigating the risk of stroke and bleeding in atrial fibrillation

IN AUSTRALIA, atrial fibrillation (AF) contributes to almost one in 10 deaths and is the most common recurrent cardiac arrhythmia, with over 500,000 people affected. 1Prevalence is rising, driven by an ageing population, an increased burden of comorbidities, increased awareness of the disease resulting in increased detection, improved detection methods and greater survival among patients with AF. 2 AF increases the risk of stroke by five-fold.Typically, patients with AF who have a stroke have large infarcts and a poor outcome with significant disability. 3 However, the appropriate use of anticoagulants in non-valvular AF can reduce the risk of ischaemic stroke by 64% and the risk of death by 26%. 4,5 Given the efficacy of anticoagulants, it is surprising and concerning that only about half of eligible patients are on anticoagulants. 6 Until direct oral anticoagulants (DOACs) were listed on the Pharmaceutical Benefits Scheme (PBS) in 2013, warfarin was the drug of choice for stroke prevention in AF, and remains so for some patients.The advantage of DOACs over warfarin is that they provide effective anticoagulation, with reduced need for regular monitoring and fewer interactions with food and drugs.Nonetheless, all oral anticoagulants are high-risk medicines